Cemented THA may play a role in revision surgery
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Despite surgeons going a cementless route with revision total hip arthroplasty, a presenter at the Current Concepts in Joint Replacement Spring Meeting noted, although rare, there is a role for cemented revision in THA.
“[Cemented revision] is going to be guided by your preference, but it is particularly indicated in the elderly, those [who are] low demand, those who are osteopenic – if the bone is poor – and, bear in mind, you need some cancellous bone,” Fares S. Haddad, MD, FRCS, said in his presentation. “If there is no cancellous bone proximally, you have to go a little bit longer; but sometimes, you can make it look like a primary.”
One technique for cemented revision is impaction grafting, which is ideal for younger patients with type 2 and 3A bone, according to Haddad. Although a difficult procedure, he noted impaction grafting can successfully restore bone and provide a durable reconstruction. However, Haddad said this technique has its problems and should be performed by surgeons who do a high volume of cemented revision THAs.
“There is a risk of fracture if you impact hard. it is tough to get a good cement mantle unless you are used to doing it. It takes much longer than doing a cementless taper,” Haddad said.
He added cement in cement revision is another technique that has become useful in cemented revision THA. As long as the patient has an intact cement mantle and a polished tapered stem, Haddad noted it is possible to “cement into old cement.”
“One caveat I have is the existing cement must be solidly fixed for you to use this technique, but it is a great get out of jail card when you have cement in situ,” Haddad said. “You just get it out and you can re-cement within it. Sometimes some fairly tricky cases can be made simple using this technique.”
Perspective
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Timothy S. Brown, MD
As Haddad writes in “Cemented stems in revision 2020: What problems do they solve?” femoral design in revision THA today is most commonly distally fixed, modular fluted-tapered titanium stems. Although many problems encountered during revision THA can be addressed with these modular cementless designs, there remain indications for which cemented fixation can offer benefits. Cemented fixation allows for immediate, full weight-bearing in patients with endoprosthesis reconstructions, the ability to locally deliver antibiotics in patients with periprosthetic joint infection and the restoration of extensive femoral bone loss with impaction grafting. Cement-in-cement revision THA for patients with an existing good cement mantle also allows for less bone loss, less blood loss and a decreased chance of fracture during cement removal at the time of revision. For revision THA, cemented femoral stems should continue to remain in the hip surgeon’s toolbox – especially for patients with prior cemented fixation, periprosthetic infection or extensive femoral bone loss.
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Haddad FS. Paper 65. Presented at: Current Concepts in Joint Replacement Spring Meeting; May 18-20, 2020 (virtual meeting).
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